Applicability of risk compensation to the relationship between health behaviors and COVID-19 vaccination among inpatients in Taizhou, China

Aim Based on the risk compensation theory, this study was designed to investigate the relationship between health behaviors of inpatients and COVID-19 vaccination during the epidemic with regard to the Omicron variant of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Taizhou, China. Subject and methods We conducted an online self-administered survey with a group of inpatients in a grade III, class A hospital in Taizhou, China, from February 27, 2022, to March 8, 2022. A total of 562 complete questionnaires were collected, and 18 questionnaires completed in under 180 seconds were rejected, leaving a total of 544 (96.8%) valid questionnaires collected. The participants who had received a COVID-19 vaccine were asked to describe the differences in their health behaviors before and after the vaccination, and the data were analyzed using SPSS Statistics version 22.0 software. Results There were significant differences in the percentage of individuals wearing masks (97.2% and 78.9%, P < 0.001) and the percentage of hand washing after taking off the mask (89.1% and 63.2%, P < 0.001) between the inoculated group and the uninoculated group; however, there were no significant differences in other health behaviors. The participants showed better health behaviors (handwashing and wearing a mask) after the vaccination than prior to it. Conclusions Our findings suggest that the Peltzman effect did not increase risk behaviors during the Omicron epidemic. There was no reduction in health behaviors among inpatients after the COVID-19 vaccine, which may have even improved their health behaviors.


Introduction
The novel coronavirus disease 19  pneumonia, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has infected 490 million people worldwide and has caused over 6.16 million deaths (World Health Organization 2021). Vaccines have proven to be an extremely effective approach to combat prior epidemics (Wadman and You 2017). A global survey showed that respondents were willing to receive the COVID-19 vaccine . With the emergence of a new Omicron mutant strain, the prevention and control of the epidemic have become more complicated and arduous. There were as many as 32-50 variants of Omicron, and 30 mutation points were concentrated on the spike proteins, which were closely related to pathogenicity and antigenicity. As a result, experts are generally concerned that the strain is more transmissible than the Delta variant, with the potential for more secondary infections and higher "drug resistance" to the vaccine. Wearing masks and gloves and handwashing in public places are some of the key measures to prevent transmission and to control the spread of the COVID-19 pandemic (Ogoina 2020;Przekwas and Chen 2020). Therefore, during the Arcanum epidemic, compliance with health behaviors was important in reducing the risk of individual infections and controlling the spread of the epidemic.
Risk compensation indicates that when people are perceived to be at risk, they naturally adjust their behaviors to compensate and reduce the risk (Hedlund 2000). However, as the novelty of the threat wears off, the effect of risk compensation tends to fade over time (Hedlund 2000). This phenomenon, in which individuals respond to safety measures with a compensatory increase in risk behaviors, is known as the "Peltzman effect," named after the University of Chicago economist Sam Peltzman (Hedlund 2000;Peltzman 1975). During the decades since its initial description, the presence of the Peltzman phenomenon has been inconsistent, since it has been observed with some security interventions but not with others (Hedlund 2000). There is also a direct relationship between risk compensation mechanisms and behavioral differences before and after vaccination. Therefore, during the epidemic with the Omicron variant, we conducted a questionnaire survey on this issue and assessed risk compensation between health behaviors of hospitalized patients in Taizhou and COVID-19 vaccination.

Research design and population
We conducted an anonymous, online, cross-sectional survey through WeChat, China's largest online survey platform, which targeted hospitalized patients in Taizhou, China. As shown in Fig. 1, a total of 562 people were asked to report their health behaviors via WeChat between February 27, 2022, andMarch 8, 2022. A total of 562 completed questionnaires were collected, among which there were 544 (96.8%) valid questionnaires and 18 questionnaires that took less than 180 seconds to complete. We examined participants' gender, knowledge, employment categories, and health behaviors such as wearing a mask, hand washing, and gatherings. The patients' experiences of negative emotions (anxiety, panic, and fear) were also recorded. Participants who had received the COVID-19 vaccine were asked to describe the differences between their health behaviors before and after the vaccination. This investigation was exempt from the need for informed consent and was approved by the Ethics Committee of Enze Hospital, Zhejiang Province, China. The participants were anonymous. The COVID-19 vaccine in this study was a Inactivated vaccine produced by Sinovac. The Chinese government has provided the COVID-19 vaccine to the public free of charge.

Questionnaire
Our questionnaire was based on a survey conducted by Sun et al. (2022) on the protective health behaviors of hospital staff during the COVID-19 pandemic in 2019. The questionnaire included the following relevant items.
(1) Basic demographic information, including gender, educational level, and professional/technical titles.
(2) Consequences of health behaviors during the Omicron epidemic: "What about wearing masks and washing hands?" (Always, Usually, Seldom, Never) (3) The status of COVID-19 vaccination, assessed by the questions: "Did you get the COVID-19 vaccine?" and "If you did, when did you get it?" (4) Comparing the health behaviors of wearing a mask, hand washing, and gatherings before and after the inoculation of COVID-19 vaccine during the epidemic with the Omicron variant. (5) Experience of negative emotions (anxiety, panic, or worry) as a result of the prevalence of the Omicron variant.

Statistical analysis
All data were analyzed with IBM SPSS Statistics version 22.0. In univariate analysis, the χ 2 test was used to assess the categorical variables between fatigued and non-fatigued participants. The main results of this investigation were the health behavior during the Omicron mutant epidemic and the difference in health behaviors before and after the inoculation. All participants provided answers about the health behaviors they followed, and whether they had been vaccinated. Follow-up questions, such as the time of the first dose, were answered by the vaccinated participants. A value of P < 0.05 was considered to represent a statistically significant difference between the test groups.

Characteristics of the study population
A total of 544 participants completed the survey. The sample consisted of 191 men (35.1%) and 353 women (64.9%) who reported health behaviors and negative emotions following an outbreak of COVID-19. Among all hospitalized patients, 506 (90.0%) received at least one dose of the COVID-19 vaccine, while 38 did not receive the vaccine. The demographic variables age, education, and occupation were also recorded. The proportions of females, middle-aged persons, and highly educated individuals in the COVID-19 vaccine group were 66.6% (P = 0.004), 55.7% (P < 0.001), and 53.6% (P = 0.011), respectively. The proportion of farmers in the uninoculated group was 36.8% (P = 0.009). These results are shown in Table 1.

Inpatients' health behaviors during the epidemic with the Omicron variant
In our survey, we examined different health behaviors of the vaccinated and unvaccinated respondents. Table 2 shows that the wearing of masks and handwashing after removing masks were associated with vaccination, while other health behaviors showed no association.

Differences in health behaviors among vaccinated individuals
As shown in Fig. 2, there was a significant difference in the number of times handwashing was done after vaccination (P = 0.049), depending on the time of the first vaccination. By comparing health behaviors before and after the vaccination, we found significant increases in mask-wearing duration, handwashing frequency, and participation in gatherings of more than 10 people in our sample (Fig. 3).

Negative emotions (anxiety, panic, and fear)
During the epidemic with the Omicron variant, our survey data showed that 79.96% of the participants had never experienced negative emotions, while only 4.76% of the participants experienced an increase in negative emotions after receiving the COVID-19 vaccine. These results are shown in Table 3.

Discussion
The study showed that inpatients who received the COVID-19 vaccine did not necessarily have fewer nondrug interventions, such as hand-washing and wearing masks than unvaccinated inpatients. Furthermore, our research showed that people who   Greaney et al. 2021).
The main sources of information mentioned in studies, such as that by Bhagavathula (2022), are the news media and government websites. Approximately one third of the participants reported that they regularly consumed news media (television/video, newspapers, radio, and magazines), whereas a quarter (24.3%) relied on the websites of national and international health agencies, including the World Health Organization (WHO), Centers for Disease Control (CDC) and Prevention, and Ministry of Health (MOH), for Omicron information. In addition, 39% of the participants sometimes discussed the Omicron strain with family and friends. The government has issued a variety of guidance documents to advise the public through WeChat, radio, news, and other means of the daily real-time release of relevant data. Simultaneously, all-level units and factories also set up epidemic prevention staff to guide and supervise the health behavior of employees within the department.
The participants in this study were inpatients. In public places, such as hospitals, special personnel has been arranged at the entrance to carry out health code, stroke code, and personnel flow track inquiries, and patients and their families are strongly advised to wear face masks. For those who do not wear masks, there is staff to remind them or issue masks to enhance the mask-wearing behavior. These measures allow people who have received the new vaccine to remain vigilant about wearing masks and to have access to medical surgical masks in public places. Even if they have forgotten their face masks, the compliance with health behaviors among inpatients increases.
These measures are effective and suitable for the national conditions of the "dynamic zero" strategy. The government uses nondrug interventions (NPI) to prevent serious outbreaks caused by the Omicron variant. First, this includes limiting the large-scale movement of people and increasing inter-provincial and inter-city traffic restrictions to reduce the cross-regional transmission of the new coronavirus. Second, the early detection and isolation of newly coronavirus-positive people and tracking of close contacts and large-scale personnel using nucleic acid screening have been emphasized. Third, the measures include increasing interpersonal distance; canceling or postponing large-scale activities, gatherings, and close-distance business entertainment places; delaying the resumption of business and school; and maintaining good personal hygiene habits. These characteristics may make inpatients more dependent on NPI and influence the outcome of health behaviors.
Although the protective effect of the new COVID-19 vaccine is declining, the protective effect on severe cases and deaths remains. However, antibodies further increase after the third injection of a "reinforcing needle"; thus, the policy of "should hit, must hit" should still be carried out.  The results of the questionnaire showed that the unvaccinated groups included mainly male individuals (57.9%, P = 0.004), individuals with low education (68.4%, P = 0.011), people employed in agriculture (36.8%, P = 0.009), and the elderly (44.7%, P < 0.001). As the world is experiencing a wave of infections with the Omicron mutation, inevitably spreading to every continent, there is an urgent need for greater efforts through educational interventions targeting the general population, to improve individuals' knowledge and understanding of the Omicron variant and to promote healthy behaviors. In particular, we need to strengthen education efforts for men, the less educated, the elderly, and farmers and to develop relevant and feasible measures to guide people to actively vaccinate. During an outbreak, it is especially important to strengthen the health of this group of people and to promote their health behaviors. However, one should not expect two or even three shots to be safe. Instead, the same strict precautions should be maintained.

Limitations
There are several limitations to this study. This was a crosssectional study conducted between late February and early March 2022, when an alarming number of cases of infection with the Omicron variant were reported worldwide that could affect the general health behavior of the population. The data presented in this study were self-reported and depend on participants' honesty and recall ability, so they may be affected by recall bias. This study was limited to inpatients in a grade III, class A hospital in Taizhou. In the future, the data will be included in a larger multicenter sample to provide evidence for a better response to the COVID-19 epidemic.
In addition, factors such as internet access, time changes, and language barriers may influence participation. Despite these limitations, the results of this study provide insight into changes in the health behaviors of hospitalized patients at the peak of the Omicron mutant pandemic.

Conclusions
In this study, the concept of risk compensation was not applicable to our results. After being vaccinated with a COVID-19 vaccine, the health behaviors of the population did not decrease and may have even improved. Further large-scale population surveys are needed to determine the applicability of the risk compensation theory in association with health behaviors and COVID-19 vaccination.